[Delphi Expert Consensus of the German Society for Thoracic Surgery on Segmentectomy for Non-small Cell Lung Cancer]

BACKGROUND

Findings from two recently published randomised controlled trials have shown favourable oncological results of segmentectomy for early-stage NSCLC < 2 cm. This has generated a growing interest in this procedure, which is however considered technically more challenging than lobectomy. The aim of the working group of the German Society for Thoracic Surgery (DGT) was to address, via an expert consensus project, topics concerning implementation of segmentectomy in lung cancer surgery.

METHODS

The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres in Germany. The steering group predefined a priori the threshold of consensus of 75% or greater. The results were discussed in an expert meeting, leading to a final Delphi poll for selected topics and questions.

RESULTS

Thirty-eight questions on segmentectomy for NSCLC were proposed in two rounds and voted on. After the final Delphi process, a consensus was reached for the following topics: non-inferiority of segmentectomy vs. lobectomy for tumours < 2 cm, segmentectomy as an alternative if lobectomy is functionally not feasible, use of intraoperative techniques for identification of intersegmental borders. No consensus could be reached for topics such as frozen section for intraoperative ascertainment of radicality, as also for the indication of a re-do lobectomy in case of an occult N1 lymph node status.

CONCLUSION

Our manuscript depicts the results of a Delphi process in 2020/2021 involving experts of the German Society for Thoracic Surgery on the implementation of segmentectomy in lung cancer patients. In general, a very high rate of consensus was documented for the majority of the topics concerning the indication and execution of lung segmentectomy.

Development and validation of a sleep questionnaire, SNoRE 3.0, to evaluate sleep in companion dogs

Disturbances in the sleep-wake cycle are a debilitating, yet rather common condition not only in humans, but also in family dogs. While there is an emerging need for easy-to-use tools to document sleep alterations (in order to ultimately treat and/or prevent them), the veterinary tools which yield objective data (e.g. polysomnography, activity monitors) are both labor intensive and expensive. In this study, we developed a modified version of a previously used sleep questionnaire (SNoRE) and determined criterion validity in companion dogs against polysomnography and physical activity monitors (PAMs). Since a negative correlation between sleep time and cognitive performance in senior dogs has been demonstrated, we evaluated the correlation between the SNoRE scores and the Canine Dementia Scale (CADES, which includes a factor concerning sleep). There was a significant correlation between SNoRE 3.0 questionnaire scores and polysomnography data (latency to NREM sleep, ρ = 0.507, p < 0.001) as well as PAMs' data (activity between 1:00 and 3:00 AM, p < 0.05). There was a moderate positive correlation between the SNoRE 3.0 scores and the CADES scores (ρ = 0.625, p < 0.001). Additionally, the questionnaire structure was validated by a confirmatory factor analysis, and it also showed an adequate test-retest reliability. In conclusion the present paper describes a valid and reliable questionnaire tool, that can be used as a cost-effective way to monitor dog sleep in clinical settings.

POS0050 B CELL CHARACTERISTICS AT BASELINE PREDICT HUMORAL RESPONSE UPON SARS-CoV-2 VACCINATION AMONG PATIENTS TREATED WITH RITUXIMAB

Background

Vaccination is considered efficient in controlling infections incl. SARS-CoV-2. Prior studies showed that patients receiving rituximab (RTX) with low B cell counts are at increased infectious risk (1) and risk of inadequate vaccination responses (2, 3). Thus, the ability to further define and predict vaccination responses in these patients may guide their optimal protection.

Objectives

To assess predictive biomarkers of vaccination responses upon SARS-CoV-2 vaccination in RTX treated patients.

Methods

B cell characteristics before vaccination were evaluated to predict responses in 15 patients with autoimmune inflammatory rheumatic diseases receiving RTX. 11 patients with rheumatoid arthritis on other therapies (RA), 11 kidney transplant recipients (KTR) and 15 healthy volunteers (HC) served as controls. A multidimensional analysis of B cell subsets and a correlation matrix were performed to identify predictive biomarkers.

Results

Significant differences regarding absolute B cell counts and specific subset distribution pattern between the groups were validated at baseline. Here, the majority of B cells from vaccination responders of the RTX group (RTX IgG+) comprised naïve and transitional B cells, whereas vaccination non-responders (RTX IgG-) carried preferentially plasmablasts and double negative (CD27-IgD-) B cells (Figure 1). Moreover, there was a positive correlation between neutralizing antibodies and absolute B cell numbers with B cells expressing HLA-DR and CXCR5 (involved in antigen presentation and germinal center formation) as well as an inverse correlation with CD95 expression and CD21low expression (marker for activation and exhaustion) on B cells.

Conclusion

Substantial repopulation of naïve B cells upon RTX therapy appears to be essential for an adequate vaccination response requiring germinal center formation. In contrast, expression of exhaustion markers (CD21low, CXCR5-, CD95+) indicate negative predictors of vaccination responses. These results may guide optimized vaccination strategies in RTX treated patients clearly requiring antigen-inexperienced B cells for appropriate protection.

References

[1]Sparks JA, Wallace ZS, Seet AM, Gianfrancesco MA, Izadi Z, Hyrich KL, et al. Associations of baseline use of biologic or targeted synthetic DMARDs with COVID-19 severity in rheumatoid arthritis: Results from the COVID-19 Global Rheumatology Alliance physician registry. Annals of the Rheumatic Diseases. 2021;80(9):1137-46.

[2]Stefanski AL, Rincon-Arevalo H, Schrezenmeier E, Karberg K, Szelinski F, Ritter J, et al. B cell numbers predict humoral and cellular response upon SARS-CoV-2 vaccination among patients treated with rituximab. Arthritis & Rheumatology. Accepted Author Manuscript.

[3]Mrak D, Tobudic S, Koblischke M, Graninger M, Radner H, Sieghart D, et al. SARS-CoV-2 vaccination in rituximab-treated patients: B cells promote humoral immune responses in the presence of T-cell-mediated immunity. Annals of the rheumatic diseases. 2021;80(10):1345-50.

Disclosure of Interests

None declared

Clinical and bronchoscopic aspects of bronchial healing after sleeve resection for lung cancer: a multivariate analysis on 541 cases

Background

Anastomotic insufficiency is a feared complication after sleeve lobectomy. Bronchoscopy can help to identify anastomoses at risk. We evaluated negative predictors of anastomotic healing using a bronchoscopic grading system in a large collective of lung cancer patients.

Methods

From 2006 to 2019, 541 sleeve lobectomies for lung cancer were performed. Anastomotic healing was documented by bronchoscopy on the seventh postoperative day using a standardized classification system for anastomotic grading (grade 1, perfect healing to 5, insufficiency). Grade 1 and 2 were considered satisfactory and the patients were discharged. Grade 3 or higher was considered critical. These patients received systemic antibiotic treatment and re-bronchoscopy was performed 4 days later.

Results

In 18.5% of the patients, the anastomosis was assessed as critical. 19% of patients with critical anastomosis on the 7th postoperative day developed anastomotic insufficiency during the postoperative course, compared to 0.2% in patients with satisfactory anastomotic healing. Bilobectomies, low preoperative forced expiratory volume in 1 second (FEV1) values, high preoperative levels of C-reactive protein and neoadjuvant radiation were identified as independent risk factors for critical anastomotic healing.

Conclusions

Bronchoscopic assessment of anastomotic healing is an effective tool to identify critical anastomoses. Neoadjuvant radiation, bilobectomies and acute or chronic inflammation were independent risk factors for bronchial healing disorders and should be considered at the planning stage of surgery.

[Resection of Lung Cancer in Old Patients - Does Demographic Change Cause a Rethink?]

Due to the demographic change prevailing in Germany, the age pyramid is shifting more and more upwards. According to the WHO, a patient over the age of 75 is considered to be old. Whether or not and to what extent an old patient can tolerate thoracic surgery purely based on his age and comorbidities remains unclear. Under most circumstances the surgeon's experience seems to be crucial in this decision. PATIENTS AND METHODS:  The data analysis included data from 01. 2016-01. 2018 based on the German Thorax Register (Project ID: 2017-03), which was set up under the patronage of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the German Society for Thoracic Surgery (DGT). A total of 1357 patients were included, 658 patients had histologically proven lung cancer stage I-II. These were divided into three groups according to their age; group I (< 65 years), group II (65- ≤ 75) years and group III (> 75 years). We were able to show that group III had essentially no increased postoperative complication rates (all = 48.00 %; group I = 40.90 %; group II = 53.00 %; group III = 52.90 %) and even performed better than group II (65 to ≤ 75) regarding pulmonary complications. (postoperative pneumonia group II = 19.20 %, group III = 12.90 %) The mortality was lowest in patients who were operated on in centers of the German Thorax Register (all = 1.70 %, group I = 1.90 %; group II = 1.70 %; group III = 1.30 %), compared to national german average. (all = 1.99 %; group I = 1.23 %; group II = 2.18 %; group III = 3.78 %) In particular, patients of group III showed the greatest difference. Furthermore, we saw that the majority of anatomical resections performed in centers of the German Thorax Register were resected by VATS (Video-assisted Thoracoscopic Surgery) as opposed to patients operated on in hospitals not affiliated with the German Thorax Register. DISCUSSION:  Considering these results, the question arises whether in Germany all old patients were treated according to current guidelines. Although there is a certain selection bias in group III, operative candidates fit for surgery are operated in the centers of the German Thorax Register. Our results permit us to conclude that this group of patients should be given optimal surgical therapy when indicated. Age alone should not be the sole determining factor in decision-making regarding thoracic surgery.

Relationship between suicide attempts of repetition and dependence to the cocaine: Report of clinical case

Introduction

People with borderline personality disorder are at higher risk of repeating suicidal behavior. At the same time, numerous publications have demonstrated the relationship between cocaine dependence and suicide attempts of repetition.

Objectives

Review the relationship between cocaine addiction, borderline personality disorder and repeated suicide attempts. Present through a clinical case the effectiveness of a comprehensive and multidisciplinary therapeutic plan with different mental health devices.

Methods

To review the psychopathological evolution of a patient with a diagnosis of borderline personality disorder; dependence to the cocaine; Harmful alcohol consumption and suicidal behavior from the beginning of follow-up in mental health services to the present. Review the existing scientific evidence on the relationship between cocaine addiction and repeated suicide attempts. Analyze the eficacy of the different treatments available.

Results

This is a longitudinal and retrospective study of the psychiatric history and evolution of a clinical case since the implementation of an individualized therapeutic program and the favorable results obtained. Intensive outpatient follow-up was carried out for high suicide risk and hospitalization in a psychiatric hospitalization unit, day care centre and therapeutic community.

Conclusions

At present, the patient remains in abstinence with remission of suicidal ideation. The literature has shown the usefulness of intensive mental health follow-up programs to achieve remission of suicidal ideation and maintain abstinence from illegal substances.

Disclosure

No significant relationships.

Schizoaffective disorder: Nosological controversies and absence of specific treatment guidelines

Introduction

Schizoaffective disorder is a psychotic disorder of controversial nosological entity. Affective symptomatology and psychotic features of varying intensity coexist simultaneously in him throughout evolution. The lack of consensus on the existence of this entity determines its diagnostic delay and the absence of specific treatment guidelines.

Objectives

To review the diagnostic criteria for schizoaffective disorder and the published scientific evidence on the efficacy and safety of the different therapeutic options available. To analyze the efficacy of a multidisciplinary treatment plan implemented in an intensive follow-up program, presenting the evolution of a clinical case.

Methods

To review the psychiatric history and psychopathological evolution of a patient diagnosed with schizoaffective disorder from the beginning of an intensive follow-up program in a day center to the present. Review the existing scientific evidence on the usefulness of the treatments used in this nosological entity.

Results

This is a longitudinal and retrospective study of a clinical case in which the areas for improvement are analyzed before implementing a multidisciplinary therapeutic program and the favorable results obtained today. Currently, the patient is euthymic and attenuated and chronic positive and negative symptoms persist that do not interfere with his functionality.

Conclusions

From the implementation of an individualized, personalized and multidisciplinary maintenance treatment plan, an overall improvement in psychopathological stability and functional recovery is observed. Among the psychopharmacological options in this patient, Paliperidone Long Acting Injection (PLAI) stands out for its long-term efficacy and safety.

Prophylaxis and management of postoperative complications after tracheobronchial surgery

Prevention of bronchial complications after airway surgery must be our primary goal. Understanding bronchial and anastomotic healing is the first step to success. This can be improved by standardizing operating technique (bronchial closure and end-to-end anastomosis) as well as postoperative care. Bronchopleural fistula after pneumonectomy still remains a feared complication with a high mortality rate. Especially after sleeve resection interpretation of endobronchial healing and postoperative measures of care with the help of an algorithm, may avoid anastomotic insufficiency and therefore reduced the secondary pneumonectomy rate.

Sleeve lobectomy versus lobectomy for primary treatment of non-small-cell lung cancer: A single-center retrospective analysis

BACKGROUND AND OBJECTIVES

It is unclear how much additional perioperative risk a sleeve lobectomy could pose in comparison to lobectomy. The objective of this analysis was to compare the complication rate, 30-day mortality, and overall survival between lobectomy and sleeve lobectomy without prior neoadjuvant treatment in non-small-cell lung cancer (NSCLC).

METHODS

This is a retrospective study using our prospective database for quality assurance in our hospital. Inclusion criteria for our study was a completed lobectomy or sleeve lobectomy for primary treatment of NSCLC.

RESULTS

In 506 patients, the tumor was treated by means of standard lobectomy. In 252 patients with central tumor localization, sleeve lobectomy was performed. Postoperative complications occurred in n:148 (29.24%) patients of the lobectomy group and in n = 76 (30.15%) of the sleeve group. The mortality rate difference between the two groups was statistically significant and favored the lobectomy group (0.78% vs. 4.76%, p = .007). Five year survival was 69.97% for the lobectomy and 65.59% for the sleeve group (p = .829).

CONCLUSION

Sleeve lobectomy for primary surgical treatment of NSCLC has comparable perioperative complications with lobectomy. Sleeve lobectomy does not seem to negatively influence survival. Postoperative mortality was higher in the sleeve group.

[German recommendations on lung and thoracic ultrasonography in patients with COVID-19]

Lung and chest ultrasound are further examination modalities in addition to computed tomography and laboratory diagnostics in patients with COVID-19. It extends the clinical-physical examination because it can examine lung surface sensitively. Lung surface pattern changes have been found in sonograms of patients with COVID-19 pneumonia and during the course of the disease. German specialist societies of clinical acute, emergency and intensive care medicine as well as imaging, which are concerned with the care of patients with SARS-CoV‑2 infection and COVID-19, have coordinated recommendations for lung and thorax sonography. This document has been created within a transparent process, led by the German Society of Interdisciplinary Emergency and Acute Medicine e. V. (DGINA), and worked out by an expert panel and delegates from the societies. Sources of the first 200 cases were summarized. Typical thorax sonographic findings are presented. International sources or standards that were available in PubMed until May 24, 2020 were included. Using case studies and multimedia content, the document is intended to not only support users but also demonstrate quality features and the potential of chest and lung sonography. The German Society for Ultrasound in Medicine (DEGUM) is carrying out a multicenter study (study coordination at the TU Munich).

Optimal timing of surgery for bronchial sleeve resection after neoadjuvant chemoradiotherapy

INTRODUCTION

Sleeve resection is an established oncological operative treatment for centrally located tumors with reduced complications compared to pneumonectomy. In cases of neoadjuvant chemoradiotherapy, the optimal timing of surgery for bronchial anastomotic healing has not been adequately explored.

MATERIALS AND METHODS

Between 2006 and 2017, 584 tracheobronchial sleeve resections were retrospectively analyzed. We selected all patients (n = 88) after sleeve lobectomy or sleeve bilobectomy for lung cancer with fully completed neoadjuvant chemoradiotherapy. Bronchial healing was assessed by bronchoscopy on the 7th postoperative day using our earlier published classification from grades 1 to 5.

RESULTS

The median interval to surgery was 50 days (interquartile range 46-53, mean 50.03 ± 3.72). Mean anastomotic grade was 2.05 ± 1.03 and in 29.5% of the patients a critical anastomosis (grade ≥3) was documented. Anastomotic healing showed optimal results (bronchoscopic grade mean value: 1.5 ± 0.70) between the 6th and 8th postchemoradiotherapy week (P = .001). All patients operated before (bronchoscopic grade mean value: 2.3 ± 1.02) or after the above period (bronchoscopic grade mean value: 2.5 ± 1.15) had an increased ratio of anastomotic healing complications.

CONCLUSION

It is safer to perform sleeve-resections for non-small cell lung cancer after neoadjuvant trimodal treatment between the 6th and 8th week of completion of chemoradiotherapy.

Changing water use and adaptive strategies along rainfall gradients in Mediterranean lupins

There is growing interest in harnessing the genetic and adaptive diversity of crop wild relatives to improve drought resilience of elite cultivars. Rainfall gradients exert strong selection pressure on both natural and agricultural ecosystems. Understanding plant responses to these facilitates crop improvement. Wild and domesticated narrow-leafed lupin (NLL) collected along Mediterranean terminal drought stress gradients was evaluated under contrasting reproductive phase water supply in controlled field, glasshouse and cabinet studies. Plant phenology, growth and productivity, water use and stress responses were measured over time. There is an integrated suite of adaptive changes along rainfall gradients in NLL. Low rainfall ecotypes flower earlier, accumulate lower seed numbers, biomass and leaf area, and have larger root:shoot ratios than high rainfall ecotypes. Water-use is lower and stress onset slower in low compared to high rainfall ecotypes. Water-use rates and ecotypic differences in stress response (Ψleaf decline, leaf loss) are lower in NLL than yellow lupin (YL). To mitigate the effects of profligate water use, high rainfall YL ecotypes maintain higher leaf water content over declining leaf water potential than low rainfall ecotypes. There is no evidence for such specific adaptation in NLL. The data suggests that appropriate phenology is the key adaptive trait to rainfall gradients in NLL because of the flow-on effects on biomass production, fitness, transpiration and stress onset, and the lack of physiological adaptations as in YL. Accordingly, it is essential to match phenology with target environment in order to minimize risk and maximize yield potential.

[Thoracic Surgical Aspects of Seriously Injured Patients]

The therapy of severely injured patients is demanding and promising only in an interdisciplinary context. From a thoracic surgical perspective, the blunt chest trauma is in the foreground; as it is the 2nd leading cause of death after traumatic brain injury. The first step is to identify the potentially life-threatening injury and its treatment (airway obstruction, prevention of gas exchange, tension pneumothorax, serious bleeding complications in lung-/vascular injuries). Pneumothorax or tension pneumothorax is present in 20% of all polytrauma patients and 50% of all patients with severe chest trauma. In most cases, the use of a chest tube is sufficient in the acute phase (90%). For complex injuries with persistent thoracic haemorrhage and haemodynamic instability of the patient or pleural fistulization with increasing skin emphysema, surgical treatment should be performed at an early interval. Nevertheless, emergency thoracotomy is rarely required at this early stage.

Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das perioperative Management bei onkologischen anatomischen Lungenresektionen

Einleitung Die anatomische Lungenresektion zur kurativen Behandlung einer malignen Grunderkrankung ist die am häufigsten durchgeführte elektive Operation in der onkologischen Thoraxchirurgie. Ziel dieses Projektes war die Erarbeitung eines Konsenses bez. der am häufigsten gestellten Fragen zum Thema perioperatives Management für elektive onkologische Lungenresektionen.

Methodik Die Arbeitsgruppe erarbeitete 2 elektronische Delphi-Fragerunden. Als Konsens wurde eine Übereinstimmung in ≥ 75% definiert. Nach der statistischen Auswertung der Ergebnisse der elektronischen Fragerunde erfolgte eine Expertenkonferenz, die in einer finalen Delphi-Abstimmung versucht hat, weiteren Konsens über strittige Themen zu erreichen.

Ergebnisse 14 Fragen bez. des perioperativen Managements für elektive onkologische Lungenresektionen konnten formuliert und abgestimmt werden. Konsens konnte für folgende Themen erreicht werden: präoperatives infektiologisches Screening, erweiterte lungenfunktionelle Diagnostik bei eingeschränkter Lungenfunktion, Verwendung eines validierten Cardiac-Risk-Assessment-Algorithmus, Überwachung des Patienten postoperativ, Thromboembolieprophylaxe, Kontrollbronchoskopie nach Bronchusmanschettenresektionen oder nach Pneumonektomie sowie Blutgasanalyse vor Entlassung. Für folgende Themen konnte kein Konsens erreicht werden: präoperative endobronchiale mikrobiologische Diagnostik, Spülung der Thoraxhöhle, standardisierte laborchemische Untersuchungen postoperativ.

Fazit Die vorliegende Arbeit fasste die Ergebnisse eines Delphi-Prozesses zusammen, der 2018/2019 mit Experten aus zertifizierten Kliniken oder hochvolumigen thoraxchirurgischen Einheiten geführt wurde. Insgesamt zeigte sich eine sehr hohe Konsensrate bez. des perioperativen Managements bei onkologischen anatomischen selektiven Lungenresektionen. Die präoperative mikrobiologische endobronchiale Diagnostik war der Hauptpunkt, wo ein Konsens nicht erreicht werden konnte.

Bronchus Anastomosis Healing Depending on Type of Neoadjuvant Therapy

BACKGROUND

Preoperative radiotherapy and/or chemotherapy of lung cancer in patients with locally advanced disease is an option in multimodal treatment. Sleeve lobectomy has an important part in decreasing complications and sparing lung function. We present our experience in a large cohort of patients after sleeve lobectomy with or without neoadjuvant treatment and standardized assessment of bronchial anastomotic healing.

METHODS

The data used for this study were collected in a prospective database in our hospital. Anastomotic healing was documented by bronchoscopy on the seventh postoperative day and thereafter only when necessary, using a standardized scoring system. From 2006 to 2017, we performed 501 sleeve lobectomies representing 19% of all lung cancer resections. A total of 365 of patients had no preoperative treatment (73%), 41 had neoadjuvant chemotherapy (8%), and 95 had radiochemotherapy (19%).

RESULTS

Using our scoring system of the bronchial anastomosis from 1 (excellent) to 5 (insufficient), we found the anastomosis was worse than grade 2 after no treatment, chemotherapy, or radiochemotherapy in 17%, 10%, and 30%, respectively (P = .002). The rate of anastomotic insufficiency was equally low after no pretreatment and chemotherapy (2.7% and 2.4%) and rose to 10.4% after radiotherapy (P = .002). Similarly, the risk for pulmonary complications was higher after radiochemotherapy (39%) compared with no pretreatment (29%) or chemotherapy (27%), respectively (P = .382).

CONCLUSIONS

Neoadjuvant radiotherapy is associated with worse wound healing of the anastomosis after sleeve lobectomy in lung cancer. There seems to be a higher risk for anastomotic insufficiency and complications.

[Surgical treatment of tracheopleural and bronchopleural fistulas after bronchoplastic resection (sleeve or bifurcation resection)]

The treatment of tracheopleural and bronchopleural fistulas at an anastomosis after sleeve resection is complex and fraught with complications. Morbidity and mortality are very high. Therefore, great care must be taken to avoid such complications. The clinical signs and the early diagnosis of a potentially critical anastomosis or anastomotic leakage as well as the treatment, including secondary pneumonectomy are presented.

Research priorities for the pan-Canadian Oncology Symptom Triage and Remote Support practice guides: a modified nominal group consensus

Introduction

The pan-Canadian Oncology Symptom Triage and Remote Support (costars) team is studying how to improve the quality and consistency of cancer symptom management.

Methods

A 1-day invitational meeting was held 24 October 2017 in Ottawa, Ontario, to review the current evidence from costars projects and to establish research priorities for a future largescale implementation study. The meeting included 36 participants who were clinicians from adult oncology, pediatric oncology, and homecare; policymakers from national, provincial, and regional organizations; researchers; and a patient. Half the day involved summarizing evidence from four costars studies and experiences with implementing the costars symptom practice guides. The second half of the day used a modified nominal group technique to generate research questions within small groups, presentation of research questions to all participants, and two rounds of voting to reach consensus on research priorities.

Results

Participants proposed 4 research categories:■ User-centred augmentation to enhance usability (for example, designing a mobile costars solution)■ Outcome measurement (for example, determining key competencies for clinicians)■ Regular renewal of costars to keep pace with evolving evidence (for example, updates for novel therapies)■ Integration into clinical practice (for example, meaningful engagement of patients and caregivers in study design).

Conclusions

Across categories, the top 3 priorities were effect on health services use, competency development, and a mobile costars solution. Future research will address identified priorities, reflecting the needs and perspectives of diverse stakeholders. Stakeholder collaboration will continue to guide our approach to operationalizing this priority research agenda.

Factors influencing the use by radiation therapists of cancer symptom guides: a mixed-methods study

Background Radiation therapists play an important role in helping patients to safely manage and triage potentially life-threatening symptoms. The purpose of the present study was to assess factors influencing the use by radiation therapists of evidence-informed symptom practice guides for patients experiencing cancer treatment–related symptoms.Methods In a mixed-methods descriptive study guided by the Knowledge-to-Action framework, interviews and a barriers survey were conducted. Two independent reviewers conducted a content analysis of interview transcripts. Barriers survey data were analyzed using frequency distributions and univariate descriptive statistics. Open-ended data from the surveys underwent content analysis and were triangulated with interview findings.Results Of 90 radiation therapists approached, 58 completed the survey (64%), and 14 were interviewed. Of the 98% who reported providing symptom management to patients undergoing radiation treatment, 53% used evidence-informed practice guidelines. Radiation therapists had moderate moral norms (4.6 of 7) and beliefs about the consequences of using costars (pan Canadian Oncology Symptom Triage and Remote Support) practice guides (4.8), but neutral intention (3.4) and beliefs about their own capabilities (3.9). Environmental barriers included lack of time (2.0), lack of access (2.5), and neutral organizational support (3.0). Radiation therapists identified a need for training (5.5). Common unique barriers to practice guide use were lack of time during radiation treatments, unclear fit with scope of practice, disparate focus on site-specific symptoms, and lack of medication knowledge.Conclusions The symptom practice guides were perceived by the radiation therapists to benefit patients, enhance their own knowledge of symptom management, and promote consistent practice. Additional work is required to identify the scope of practice of radiation therapists within the interprofessional team.

Factors influencing the use by radiation therapists of cancer symptom guides: a mixed-methods study

Background

Radiation therapists play an important role in helping patients to safely manage and triage potentially life-threatening symptoms. The purpose of the present study was to assess factors influencing the use by radiation therapists of evidence-informed symptom practice guides for patients experiencing cancer treatment-related symptoms.

Methods

In a mixed-methods descriptive study guided by the Knowledge-to-Action framework, interviews and a barriers survey were conducted. Two independent reviewers conducted a content analysis of interview transcripts. Barriers survey data were analyzed using frequency distributions and univariate descriptive statistics. Open-ended data from the surveys underwent content analysis and were triangulated with interview findings.

Results

Of 90 radiation therapists approached, 58 completed the survey (64%), and 14 were interviewed. Of the 98% who reported providing symptom management to patients undergoing radiation treatment, 53% used evidence-informed practice guidelines. Radiation therapists had moderate moral norms (4.6 of 7) and beliefs about the consequences of using costars (pan-Canadian Oncology Symptom Triage and Remote Support) practice guides (4.8), but neutral intention (3.4) and beliefs about their own capabilities (3.9). Environmental barriers included lack of time (2.0), lack of access (2.5), and neutral organizational support (3.0). Radiation therapists identified a need for training (5.5). Common unique barriers to practice guide use were lack of time during radiation treatments, unclear fit with scope of practice, disparate focus on site-specific symptoms, and lack of medication knowledge.

Conclusions

The symptom practice guides were perceived by the radiation therapists to benefit patients, enhance their own knowledge of symptom management, and promote consistent practice. Additional work is required to identify the scope of practice of radiation therapists within the interprofessional team.

Pain and health-related quality of life (HRQoL): a national observational study in community-dwelling older adults

PURPOSE

Regarding the epidemiology of pain in older adults, data are lacking about the association between pain severity and its impact on health-related quality of life (HRQoL). This study was aimed to investigate pain prevalence and sites, self-reported interferences with daily life activities, and the effect of pain severity on HRQoL in a Swiss community-dwelling population aged ≥ 65 years.

METHODS

This is a cross-sectional survey conducted with a national sample of individuals randomly selected from population records, stratified by age and gender. Respondents answered a face-face interview addressing pain location, intensity and interferences, and quality-of-life variables. Logit regression models were applied for binary outcomes, linear regression for continuous outcomes, and Poisson regression for count outcomes. For each analysis, Wald Chi square and 95% confidence intervals were used.

RESULTS

Among the 2995 individuals considered, 36.4% reported pain. The results indicate that pain prevalence and intensity increased from age 80 onwards. Pain intensity was strongly associated with functional health, i.e., all scales involving physical activities were affected in individuals reporting severe pain; it was also associated with the individuals' perception of their overall HRQoL.

CONCLUSION

Our results point to the importance of devoting attention to pain intensity rather than to the number of pain sites. Because of the demographic transition, the management of pain problems should emphasize early referral and timely treatment to prevent the burden of disease and functional loss associated with pain intensity.

Perioperative outcome after open and thoracoscopic segmentectomy for the treatment of malignant and benign pulmonary lesions: a propensity-matched analysis

Background

The aim of this study was to compare the perioperative outcome of patients receiving anatomic segmentectomy either by open surgery or video-assisted thoracoscopic surgery (VATS). To assess the short-term morbidity of the procedure itself, lung cancer patients in all stages as well as patients with pulmonary metastases and benign lesions scheduled for segmental resection were enrolled in this study.

Methods

A retrospective analysis of prospectively collected data on 445 consecutive patients that underwent segmentectomy either by VATS (n=233) or thoracotomy (n=212) was performed. A propensity-matched analysis was conducted based on age, gender, smoking history, histology, tumor size, forced expiratory volume in 1 second (FEV1) and history of previous pulmonary resections. The matched sample included two groups of 140 patients each.

Results

Both study groups were comparable with respect to age, gender, smoking history, diagnosis, tumor size, pulmonary function and history of previous pulmonary resections. VATS segmentectomy was associated with decreased length of stay (7.4 vs. 9.5 days, P<0.001), drainage treatment time (4.7 vs. 5.9 days, P=0.012) and severe postoperative complications (1.4% vs. 7.1%, P=0.018).

Conclusions

VATS segmentectomy is safe and effective for the treatment of benign and malignant pulmonary lesions. Compared with open thoracotomy, it is associated with shorter hospitalization time and decreased number of severe complications. The preservation of functional lung tissue, combined with a minimally invasive approach, make VATS segmentectomy highly suitable for patients with reduced pulmonary function or severe comorbidities.

The impact of low back pain on health-related quality of life in old age: results from a survey of a large sample of Swiss elders living in the community

PURPOSE

The present study aims at investigating the effects of low back pain (LBP), i.e., type of symptoms, activity limitations, frequency, duration, and severity on health-related quality of life (HRQoL) in a sample of 707 community-dwelling men and women aged ≥ 65 years living in Switzerland.

METHODS

The study is part of a larger survey conducted in Switzerland on a sample of older adults selected randomly from population records, stratified by age and sex. The Standardized Back Pain Definition was used to investigate LBP, and HRQoL was assessed by means of the EQ-5D, including Health Utility Index (HUI) measures.

RESULTS

For more than half of the sufferers, pain was chronic, occurred most days or every day and induced activity limitations. One-third of the sufferers reported sciatica symptoms. Individuals reporting every day pain, severe pain and more than 3 years since the last episode without pain lost nearly 10 points of HRQoL. Amongst the dimension of HRQoL, Mobility was the most affected by LBP.

CONCLUSIONS

These results provide further insight into the impact of qualitative aspects of LBP and in particular the importance of radiating leg pain and pain frequency and duration. While LBP-related activity limitations had little impact on both self-rated overall health and HUI, radiating leg pain and pain frequency and duration were associated with significantly decreased scores on both dimensions.

[Trimodal Therapy for Stage IIIA-B NSCLC Involving High Dose Neoadjuvant Chemoradiotherapy. Is Surgery a Rational Option?]

Introduction Stage III non-small cell lung cancer (NSCLC) and its possible multimodal therapy present a challenge to the responsible oncologist, chest surgeon and radiologist. The aim of the present retrospective study was to analyse and evaluate the treatment algorithm in our hospital for patients with stage III NSCLC (intention to treat). We compared an aggressive treatment regime with primary trimodal therapy (high dose radiochemotherapy and resection), independently of "multilevel" N2 or "single level" N3 status. These results were then compared with a historical group of our patients who solely received simultaneous radiochemotherapy (bimodal therapy). Materials and Methods Within the period of the study, 156 patients were diagnosed with stage III NSCLC and treated with trimodal therapy. The median age was 71 years. 103 patients (60%) were male, 53 (34%) female. In the group with bimodal therapy, 102 patients were evaluated. Results After radiological restaging and checking functional resectability, 90 patients (57.7%) in the trimodal therapy group received secondary resection, including 37 (41.1%) lobectomies/bilobectomies, 37 (41.1%) sleeve lobectomies, 13 (14.4%) pneumonectomies and 3 (3.3%) segmentectomies (for severely restricted pulmonary function). The median survival time in the trimodal therapy group was 535 days and in the bimodal group 388 days; this difference was not statistically significant (p = 0.1377). Finally the 5-year survival after actual therapy was performed ("as-treated trimodally" vs. "as-treated bimodally"). The median survival time was then 807 days for trimodal therapy and 427 days for bimodal therapy. Conclusion High dose neoadjuvant radiochemotherapy followed by secondary resection is still a valuable option for selected patients with stage III NSCLC. However, this retrospective analysis failed to find a statistically significant survival advantage for the "intention-to-treat" trimodal patients.

[Bronchial Sleeve Resection: New Techniques and Management of Complications]

Bronchial sleeve resection is the treatment of choice for centrally located lung cancer, even in patients with normal lung function. The objective is to preserve lung tissue and avoid both pneumonectomy and its complications related, in terms of long-term survival and quality of life. As our experience in minimally invasive surgery increases, we have modified technological aspects to adapt to the new situation. This article focuses on these new technical aspects and literature data on bronchial sleeve resection.

[The German Thorax Registry: Implementation of an Established Tool of Perioperative Health Care Research]

The collection of clinical treatment data in registry databases is an important aspect of health services research. It allows for a critical evaluation of the safety, efficacy and cost-effectiveness of clinical treatment concepts in large patient populations. The findings of registry research represent real-world patients and treatment structures as they are not limited by strict inclusion criteria or unrealistic conditions as applied in prospective clinical trials. The implementation of the German Thorax Registry has enabled the collection and analysis of data on the interdisciplinary care (thoracic surgery, anaesthesiology, intensive care, pain management) of patients undergoing thoracic surgery. Under the auspices of the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Thoracic Surgery, a registry of the Hospital of the University Witten/Herdecke-Cologne, purely surgical at first, was expanded in close cooperation with the University Hospital of Freiburg. After a comprehensive data protection concept was drafted and a test phase completed, the German Thorax Registry was officially launched in January 2016. Most notably, participating hospitals profit from the registry's "benchmarking" services. "Benchmarking", i.e. the comparison of treatment quality between different hospitals, enables participants to identify individual profiles, strengths and weaknesses on a nation-wide level and follow their own progress over the course of several years. An online database for data entry and benchmarking is always accessible (www.thoraxregister.de). In October 2016, the spectrum of participants was expanded to include all hospitals performing at least 50 thoracic operations a year.

Management of chest trauma

Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.

Impact of intercostal paravertebral neurectomy on post thoracotomy pain syndrome after thoracotomy in lung cancer patients: a randomized controlled trial

BACKGROUND

Thoracotomy leads to chronic neuropathic pain in up to 50% of patients and is responsible for an impaired quality of life. Intercostal nerve injury has been suggested to be responsible for this pain. In the present study the impact of paravertebral intercostal neurectomy on post thoracotomy pain was assessed.

METHODS

In this single center parallel-group randomized controlled trial patients underwent muscle sparing anterolateral thoracotomy and anatomical lung resection for lung cancer. A subcostal approach was used for thoracotomy with single paravertebral neurectomy being performed at the beginning of the procedure at the level of the retracted intercostal space. For documentation of neuropathic pain the Leeds Assessment Score for Neuropathic Symptoms and Signs (LANSS) was used postoperatively. The primary endpoint was defined as LANSS ≥12 points on day 120. In addition, the numeric pain rating scale (NRS) was used to score pain intensity.

RESULTS

Out of 172 patients initially randomized 161 patients were investigated following intraoperative and postoperative drop-out criteria. All patients required anatomical lung resection via thoracotomy. Five patients were lost for follow up. For the remaining 156 patients there was no difference between the two groups with regard to LANSS ≥12: 26.6% in patients with neurectomy and 28.8% in control-subjects (P=0.78). In addition, the NSR score at day 120 did not differ significantly at rest and during activity between the two groups (at rest: 21.7% vs. 15.8% P=0.439; activity: 24.5% vs. 21.9% P=0.735).

CONCLUSIONS

Neurectomy was not shown to reduce the post thoracotomy pain syndrome in patients with anatomical lung resection following anterolateral muscle sparing thoracotomy.

Patterns of early resuscitation associated with mortality after penetrating injuries

BACKGROUND

Penetrating injuries are rare in European populations so their management represents a particular challenge. The aim was to assess early therapeutic aspects that are associated with favourable outcomes in patients with penetrating trauma.

METHODS

Patients with penetrating injuries documented from 2009 to 2013 in the TraumaRegister DGU® were analysed. Patients with a primary admission and an Injury Severity Score (ISS) of at least 9 were included. The Revised Injury Severity Classification (RISC) II score was used for mortality prediction, and a standardized mortality ratio (SMR) calculated per hospital. Hospitals with favourable outcome (SMR below 1) were compared with those with poor outcome (SMR 1 or more).

RESULTS

A total of 50 centres had favourable outcome (1242 patients; observed mortality rate 15.7 per cent) and 34 centres had poor outcome (918 patients; observed mortality rate 24.4 per cent). Predicted mortality rates according to RISC-II were 20.4 and 20.5 per cent respectively. Mean(s.d.) ISS values were 22(14) versus 21(14) (P = 0.121). Patients in the favourable outcome group had a significantly shorter time before admission to hospital and a lower intubation rate. They received smaller quantities of intravenous fluids on admission to the emergency room, but larger amounts of fresh frozen plasma, and were more likely to receive haemostatic agents. A higher proportion of patients in the favourable outcome group were treated in a level I trauma centre. Independent risk factors for hospital death following penetrating trauma identified by multivariable analysis included gunshot injury mechanism and treatment in non-level I centres.

CONCLUSION

Among penetrating traumas, gunshot injuries pose an independent risk of death. Treatment of penetrating trauma in a level I trauma centre was significantly and independently associated with lower hospital mortality.

Spontaneous regression of non-small cell lung cancer after biopsy of a mediastinal lymph node metastasis: a case report

INTRODUCTION

Spontaneous regression of cancer is defined as a complete or partial, temporary or permanent disappearance of tumor in the absence of specific therapy. With only a few cases reported, spontaneous regression is extremely rare in primary lung cancer. Regarding spontaneous regression in lung cancer, recent investigations revealed the role of immunological mechanisms, thus indicating potential treatment options by specific immunotherapy in the future.

CASE PRESENTATION

A 76-year-old Caucasian man with progressive dyspnea presented to our hospital. A computed tomography scan revealed a tumor mass in the upper lobe of his right lung and enlarged mediastinal lymph nodes. A biopsy of a paratracheal lymph node by mediastinoscopy disclosed metastatic lung cancer. By immunohistochemical findings the tumor was classified as large cell carcinoma. Diagnosed with clinical stage IIIA non-small cell lung cancer, a neoadjuvant therapy concept was indicated. However, before starting chemoradiation, a computed tomography scan showed a regression of both the tumor mass in the upper lobe of his right lung and the mediastinal lymphadenopathy. As a repeated computed tomography scan showed further regression, we agreed with our patient to perform routine follow-up instead of starting therapy. To date, no relapse has been reported.

CONCLUSIONS

Given the circumstances that regression started after the biopsy and involved both the tumor in the upper lobe of his right lung and the mediastinal lymph node metastases, an immune response is a reasonable explanation for the observed spontaneous regression in this case.

[Review of the Literature for Interpretation of Endobronchial Wound Healing after Tracheobronchial Sleeve Resection]

Sleeve resection comprises 3.1 % to 27.7 % of all anatomic lung resections performed in Germany. Anastomotic insufficiency is a feared complication that should be avoided. When anastomotic insufficiency does lead to secondary pneumonectomy, postoperative morbidity and mortality is high (30 % to 80 %). It is therefore very important to standardize the technique of sleeve resection as well as postoperative care. The time-point of postoperative follow-up and the interpretation of endobronchial healing have not yet been defined. In this paper anastomotic healing is described and interpreted with the help of a 5-step classification that allows bronchoscopic evaluation and classification of the anastomosis. The aim is to provide a standardized algorithm for postoperative care after sleeve resection. The basis of this classification and postoperative care measures derived from it are described and illustrated with the help of clinical examples.

[Reduction of Tracheotomy Associated Tracheal Stenosis by Surgical Closure of the Tracheostomy]

BACKGROUND

The most common long-term complication of tracheotomy is the benign stenosis of the trachea, which is described for up to 20% of the cases. Typically, the stenosis occurs after decannulation in the context of secondary wound healing. This study examined whether the closure of the tracheostomy by surgical procedure reduces stenosis.

METHOD

With the help of our clinical database a retrospective analysis of 401 surgical tracheotomies was performed. Variables that were recorded were the indication for tracheotomy, the clinical course and complications occurred.

RESULTS

155 patients were successfully decannulated. In 92 of these patients the tracheostomy was closed by a surgical procedure, in 63 cases the closure occurred spontaneously by wound healing. After decannulation 3% (n=3) of the surgically closed and 22% (n=14) of the spontaneously closed tracheostomies developed a symptomatic tracheal stenosis (p<0.001).

CONCLUSION

Secondary wound healing of the tracheostomy often leads to symptomatic tracheal stenosis. The incidence of symptomatic tracheal stenosis was significantly reduced applying closure of the tracheostomy by surgical procedure.